Box jellyfish envenomation: Difference between revisions

(Text replacement - "BSA" to "BSA")
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[[File:Avispa marina cropped.png|thumb|Box jellyfish]]
[[File:Avispa marina cropped.png|thumb|Box jellyfish]]
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
[[File:Nematocyst discharge.png|thumb|Nematocyst stages of discharge]]
*cnidarian invertebrates distinguished by their cube-shaped medusae
*Cnidarian invertebrates distinguished by their cube-shaped medusae
*"Chironex fleckeri" cause of most deaths
*''Chironex fleckeri'' or [[sea wasp]]is cause of most deaths
*largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely
*Largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely
*most stings are benign (local treatment only), only a few species have been implicated in human deaths
*Most stings are benign (requiring local treatment only), only a few species have been implicated in human deaths


===Mechanism===
===Mechanism===
*specific venom components unclear
*Specific venom components unclear
*thought to affect sodium/potassium/calcium channels
*Thought to affect sodium/potassium/calcium channels
*''Chironex fleckeri'' venom causes cell membranes to become porous allowing K+ influx/hyperkalemia
*''[[Sea wasp|Chironex fleckeri]]'' venom causes cell membranes to become porous allowing K+ influx/hyperkalemia


==Clinical Features==
==Clinical Features==
*stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched pattern
*Stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched pattern
**may progress to blisters/necrosis
**May progress to blisters/necrosis
*25-30% may still have tentacles attached
*25-30% may still have tentacles attached
*systemic envenomation (usually >10% [[BSA]]) can manifest as cardiac arrhythmias, respiratory dysfunction, death
*Systemic envenomation (usually >10% [[BSA]]) can manifest as cardiac [[arrhythmias]], [[respiratory distress|respiratory dysfunction]], death
**usually manifests within 5 minutes of sting
**usually manifests within 5 minutes of sting
*delayed hypersensitivity reactions occur in >50%
*delayed [[hypersensitivity reaction]]s occur in >50%
**itching, redness at sting sites 7-14d after initial incidence
**[[Pruritus|Itching]], redness at sting sites 7-14d after initial incidence


==Differential Diagnosis==
==Differential Diagnosis==
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==Management==
==Management==
*pain control
*Pour liberal amounts of vinegar  
*pour liberal amounts of vinegar and remove any tentacles
*Remove any tentacles
**tentacles separated from medusae can still emit venom
**tentacles separated from medusae can still emit venom
*supportive measures for minor envenomations (ice recommended but heat may actually work better)
*Pain control
*[[antihistamines]] and [[steroids]] for [[hypersensitivity reaction]]
*Supportive measures for minor envenomations  
*do NOT pressure bandage
**Ice recommended but heat may actually work better
*antivenom for life-threatening envenomations
*[[Antihistamines]] and [[steroids]] for [[hypersensitivity reaction]]
**ovine IgG Fab with 20,000 units/ampule
*Do NOT pressure bandage
*Antivenom for life-threatening envenomations
**Bovine IgG Fab with 20,000 units/ampule


===Antivenom Indications^===
===Antivenom Indications^===
*[[cardiac arrest]]
*[[Cardiac arrest]]
**undiluted antivenom administered as an IV Push: up to 6 vials
**undiluted antivenom administered as an IV Push: up to 6 vials
**if no response then give magnesium IV
**if no response then give [[magnesium]] IV
*[[hypotension]], [[tachycardia]], [[shock]], [[arrhythmia]]
*[[Hypotension]], [[tachycardia]], [[shock]], [[arrhythmia]]
**dilute 3 amps antivenom in 100mL [[NS]] and run over 20 minutes
**dilute 3 amps antivenom in 100mL [[NS]] and run over 20 minutes
**can repeat for a total of 6 vials
**can repeat for a total of 6 vials
*intractable pain
*Intractable pain
**give 1 amp diluted in 100mL [[NS]] run over 20 minutes
**give 1 amp diluted in 100mL [[NS]] run over 20 minutes


^anti-venom can cause serum sickness 4-14 days after administration
''Anti-venom can cause serum sickness 4-14 days after administration''


==Disposition==
==Disposition==

Revision as of 15:26, 8 September 2019

Background

Box jellyfish
Nematocyst stages of discharge
  • Cnidarian invertebrates distinguished by their cube-shaped medusae
  • Chironex fleckeri or sea waspis cause of most deaths
  • Largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely
  • Most stings are benign (requiring local treatment only), only a few species have been implicated in human deaths

Mechanism

  • Specific venom components unclear
  • Thought to affect sodium/potassium/calcium channels
  • Chironex fleckeri venom causes cell membranes to become porous allowing K+ influx/hyperkalemia

Clinical Features

  • Stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched pattern
    • May progress to blisters/necrosis
  • 25-30% may still have tentacles attached
  • Systemic envenomation (usually >10% BSA) can manifest as cardiac arrhythmias, respiratory dysfunction, death
    • usually manifests within 5 minutes of sting
  • delayed hypersensitivity reactions occur in >50%
    • Itching, redness at sting sites 7-14d after initial incidence

Differential Diagnosis

Marine toxins, envenomations, and bites

Evaluation

  • Generally a clinical diagnosis

Management

  • Pour liberal amounts of vinegar
  • Remove any tentacles
    • tentacles separated from medusae can still emit venom
  • Pain control
  • Supportive measures for minor envenomations
    • Ice recommended but heat may actually work better
  • Antihistamines and steroids for hypersensitivity reaction
  • Do NOT pressure bandage
  • Antivenom for life-threatening envenomations
    • Bovine IgG Fab with 20,000 units/ampule

Antivenom Indications^

  • Cardiac arrest
    • undiluted antivenom administered as an IV Push: up to 6 vials
    • if no response then give magnesium IV
  • Hypotension, tachycardia, shock, arrhythmia
    • dilute 3 amps antivenom in 100mL NS and run over 20 minutes
    • can repeat for a total of 6 vials
  • Intractable pain
    • give 1 amp diluted in 100mL NS run over 20 minutes

Anti-venom can cause serum sickness 4-14 days after administration

Disposition

See Also

References

  1. Bastian Bentlage, Paulyn Cartwright, Angel A. Yanagihara, Cheryl Lewis, Gemma S. Richards and Allen G. Collins.Evolution of box jellyfishes (Cnidaria: Cubozoa), a group of highly toxic invertebrates. Proceedings of the Royal Society, November 18, 2009 DOI:10.1098/rspb.2009.1707
  2. Currie BJ, Jacups SP. Prospective study of Chironex fleckeri and other box jellyfish stings in the “Top End” of Australia’s Northern Territory. Med J Aust 2005; 183: 631-636
  3. Hughes RJ, Angus JA, Winkel KD, Wright CE. A pharmacological investigation of the venom extract of the Australian box jellyfish, Chironex fleckeri, in cardiac and vascular tissues. Toxicol Lett. 2012 Feb 25;209(1):11-20. Epub 2011 Dec 2.
  4. http://www.toxinology.com/generic_static_files/cslavh_antivenom_boxjelly.html
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